Vaccine confidence: an interview with Dr Heidi Larson

Can you tell us about the Vaccine Confidence Project?

Here at the London School of Hygiene and Tropical Medicine we are running a project called the Vaccine Confidence Project and we have a global surveillance monitoring information around the world on media, social media, all sorts of information, reports from governments, UN, other sources, looking for any what we call “signals” of public distrust or concerns that come up.

The project was particularly catalysed in 2003 by a big boycott in Northern Nigeria of the polio vaccine. It took several months before people understood that this was actually more than just a few rumors – 5 states had boycotted the polio vaccine and it has led to the global spread of polio and still to this day, almost a decade later, it is still where we have our worst problems.

Following that there was the 2009 H1N1 debacle where the public confidence in vaccines was quite dismal. We’ve had a number of episodes around the world where the public has been questioning and not accepting vaccines, but in the public health community the main thing that is focussed on is adverse events and specific safety concerns.

I’m an anthropologist by training and I used to head up Global Communication for Immunization at UNICEF and we started to see an epidemic of outbreaks of public concerns about vaccines – communities, even governments sometimes questioning:

do we need this vaccine or that vaccine

is that vaccine relevant

is it safe

is it really the best choice for our population

we don’t like this schedule etc.

The objective of this project is firstly listening – so that when we hear signals of concerns we address them early and don’t wait until they become a crisis.

Secondly, an objective is to create a typology of concerns – what are the concerns because they are not just about safety they are about a number of other things:-

some of them are related to beliefs - philosophy, religious

some are distrust about the motives – is this big business trying to come in with an expensive vaccine?

sometimes it’s the schedule – “my baby is too young to have these vaccines”; “there’s too many of them”

Some of them are straight forward safety concerns

The objective is early detection of concerns so that the public can get answers to their questions before we have breakdowns in public trust leading to refusals.

What are the main reasons why the public may not trust a vaccine?

Some of them are prompted by genuine concerns about safety. Every vaccine has a very small risk like any medicines you take, or walking out the door on a morning – life has its risks! People want to know what is the vaccine’s risk relative to the benefit. The problem is because we’ve been so successful with immunization, and people see less of the diseases they are preventing; there has been a shift to focussing more on the risk of the needle and the reaction than the risk of the disease.

It’s different when you see a disease coming around the bend that is either fatal or can make you very sick, your willingness to take a risk is higher than when you are not seeing the pressing disease.

Sometimes the reason is motive. There was a lot of concern about the H1N1 vaccine. It exposed to the public health community how little the public really understands about the annual flu vaccine because some of the anxieties were about how quickly the H1N1 vaccine was made and whether we could trust it.

Actually every year a new flu vaccine is made from a sampling of flu viruses around the world and the H1N1 vaccine wasn’t made any quicker than the normal annual flu vaccine. The scale of production was a relatively quick amount of time, but I think that people felt like it was made too quickly; they didn’t trust it; they didn’t trust the prediction that this was going to be a very bad pandemic. It could have been a very bad pandemic and had it have been a bad pandemic I think people would have felt differently.

So, some of the reasons are about safety, some are motives, some of them are about relevance: do we really need this. We have a group of paediatricians in India that were questioning whether the country needed to introduce theHaemophilus influenzae type B vaccine (the Hib) when the country wasn’t getting enough of the very basic childhood vaccines. So sometimes countries need to make choices.

The distrust and the questioning happens at many levels:

parents

community leaders

health professionals

policy makers

We are trying to monitor all of it.

What are the implications of a lack of public trust for immunization programmes and policies?

The implications can be disastrous. They can be little or very big. The biggest concern that we have is that people get distrusted to the point that they refuse a vaccine and then the biggest concern about that is that it risks having disease outbreaks and if they are not manageable then we have a major public health problem.

I would say that is the biggest concern in one vaccine, but what also is a big risk is when people start having distrust about one vaccine or one issue it leaks into other areas of confidence in the health programme, confidence in other vaccines. So it has a reputational risk as well as a specific risk of refusals or disease outbreaks.

Where do vaccine rumours emerge?

They happen everywhere around the world but one of the things that we’re looking at is monitoring over time because you can see that sometimes you have a little emergence of a rumour or questioning in Congo – it comes for a few days and then disappears – we are not so worried about this.

In another situation in Northern India for example or Pakistan we start to get one, two, three and persisting rumors spreading misinformation leading to people starting to refuse vaccines - then we get very concerned.

We code all of our reports that we get in every day:

green means it is just information about a vaccine, new information but it doesn’t have a negative tone to it

yellow means it is an emerging concern and we need to pay attention to it

red means we should get on the phone and talk to either the local authority or the World Health Organization because the signal is about a child dying; or a perception of a link to a vaccine; or a community boycotting a vaccine.

We have concerns in the US and in Europe. Europe actually is having quite a few issues with vaccine acceptance – different ones in different countries. Some of them have to do with the history of a previous problem. In the UK for instance the MMR anxieties followed the mismanagement of the mad cow bovine encephalopathy. In France it was after the tainted HIV blood that there was a concern about a hepatitis B vaccine.

Public have memories and they remember all of that. So we are also looking at the contextual factors – what else is going on at the same time. We can have one rumor in the Congo and the same rumor in India. In the Congo it doesn’t go anywhere and in another situation the ground is fertile for the spread and the impact. Our research is trying to better understand what are the factors that make a small rumor into a big impact.

Every day there’s lots of rumors, misinformation and questions circulating around and some of them are healthy questioning and some of them can have quite negative impacts. So our work here is to help come up with criteria as a diagnostic tool that can help governments and public health officials see where they should focus their attention when a concern comes up.

Can you give some examples of vaccine rumors?

A big one is based on the research in the UK that came out in 1998 about the MMR vaccine causing bowel disease and autism. It took 10 years for that research to be withdrawn and there have been multiple reports and studies that have delinked any causal connection and we still have people who are afraid.

That actually came from a sophisticated, academic journal but it happened to be research where the findings were proven not to be true. The beginnings of that were legitimate – I trust what I read in the Lancet etc. but even when science said that it didn’t work it stayed in the minds of people. To this day it is spreading around the world. I just did an article on the emergence of anti-vaccination groups in South Africa that 12 years later were just starting here because of that rumor.

Another one was in India they were starting to try out the introduction of a HPV vaccine in 2 states to look at the different delivery options and there was a group of women activists and a member of parliament connected with an anti-vaccination group in the US and basically persuaded the government to shut down the project for a number of reasons:-

they said, “why are pushing an expensive vaccine when we don’t even have cervical screening – this must be big business trying to make money”

“it’s not safe; don’t you know it’s not safe? Our friends in the US (our “anti-vaccination” friends) told us it’s not safe”

another issue was the place where they were doing the demonstration included girls which they called ‘tribal girls’ and girls that they thought weren’t ethically appropriate to be involved in it

Usually the ones that have real impact are usually a mix of factors.

Where can readers find more information?

About Dr Heidi Larson

Dr. Heidi Larson is a Senior Lecturer at the London School of Hygiene and Tropical Medicine where she currently leads a research group studying issues around public trust in vaccines and the implications for immunization programmes and policies. (“The Vaccine Confidence Project”, see: www.vaccineconfidence.org)

Dr. Larson previously headed Global Communication for Immunization at UNICEF and Chaired the Advocacy Task Force for the Global Alliance for Vaccines and Immunization (GAVI).

Her research specializes in the analysis and evaluation of health and development programmes with particular attention to social and political factors which can affect policies and programmes.

Her particular focus is on risk and rumour management in health programmes and technologies, especially vaccines- from clinical trials to delivery - and building public trust.

Publications include:

“Addressing the Vaccine Confidence Gap” (Lancet 2011),

“Public Health Response to Influenza A(H1N1) as an Opportunity to Build Public Trust” (JAMA 2010),

“The India HPV-vaccine suspension” (Lancet, 2010)

“Protecting Public Trust in Immunization” in (Pediatrics 2008)

She has lectured internationally on issues in public trust, vaccines and health.

Dr Larson is also a Research Associate at the Harvard Center for Population and Development Studies and a Fellow at the Chatham House Centre on Global Health Security.

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